paranasal-sinus-slides-2010-11-22.pdf

Paranasal Sinus Mucoceles

Ashley Agan, MSIV Faculty Advisor: Patricia A. maeso, MD

University of Texas Medical Branch Department of Otolaryngology

Grand Rounds Presentation November 22, 2010

Outline

Introduction

Anatomy

Physiology

Pathophysiology

Symptoms

Treatment

Case Presentation

Introduction

What is a mucocele? Mucoceles are epithelium-lined, mucus-containing sacs

that completely fill a paranasal sinus

Caused by obstruction of the sinus ostium or obstruction of a mucous secreting gland

Benign

Expansion can cause destruction of surrounding structures

Infected mucopyocele

Epidemiology Rare in United States

Can take as many as 10-15 years to produce symptoms

Most commonly found in frontal and ethmoid sinuses

Japan increased incidence of maxillary sinus mucoceles Radical surgery was common for sinusitis

Prevalence

1978 Natvig and Larsen 112 patients with mucoceles from 1947 to 1974

77% Frontal Sinus

14% Frontal/anterior ethmoid

5% Anterior ethmoid

1% Posterior ethmoid

3% Maxillary

Anatomy Maxillary Sinus

Anatomy Frontal Sinus

Anatomy Frontal Sinus

Funnel-shaped

Vary in size and shape

Generally have central septum

Floor slopes inferiorly to the midline

Primary ostium located on the floor close to the midline

Frontal Recess Hourglass-like narrowing between frontal sinus and anterior middle meatus Obstruction results in a loss of ventilation and mucus clearance from frontal sinus

Anatomy

Sphenoid Sinus

Physiology

Sinuses are lined by ciliated respiratory epithelium

Mucous blanket on surface

Cilia propel mucus in specific pattern of flow mucociliary clearance

Maxillary Sinus

Mucous flow originates in the antral floor

Flow is directed centripetally toward primary ostium

Frontal Sinus

Mucous flows up medial wall, laterally across roof, and medially along floor

Some mucous exits through primary ostium

The rest is recirculated

Appearance

Macroscopically Thick walled grayish cyst

Histology Pseudo-stratified columnar epithelial cells

Few ciliated cells

Sterile mucus and cholesterol crystals

Hypertrophic goblet cells

Fibrous thickening of submucosa

Pathophysiology

Obstruction of ostium or outflow tract or of mucus secreting gland

Inflammation Trauma/Surgery

Fractures Caldwell Luc Procedure

Mass Radiotherapy scarring

Caldwell Luc Procedure

Pathophysiology

Secretion of mucus continues accumulation

Pressure increases

Bone devascularization

Osteolysis

Pathophysiology

Inflammation cytokines

IL-1, -6

TNF alpha

PGE2

Bone resorption by osteoclasts

Clinical Features Headache

Facial pressure

Facial swelling/deformity

Dental Pain

Nasal Obstruction

Ophthalmic manifestations Proptosis, Periorbital pain,

Impaired ocular mobility, Blurred/loss of vision, Diplopia

Neurologic manifestations Confusion Meningitis CSF leak

Ophthalmic Manifestations

Maxillary, Frontal, Anterior ethmoids

Proptosis, Periorbital pain, decreased ocular mobility

Pressure on globe pushes it outwards

Expansion on to extraocular muscles restricts movement

Ophthalmic Manifestations Sphenoid, posterior ethmoids

Blurred vision & decreased ocular mobility

Expansion of sinus wall may compress optic nerve or compromise its blood supply optic atrophy

Direct spread of suppuration optic neuritis

Involvement of abducent or oculomotor nerve can cause palsy

Complications

Vision loss Associated with sudden onset of visual loss by spread of

infection or inflammation to optic nerve poor prognosis (permanent blindness)

Gradual vision loss caused by ischemia better prognosis (resolution of ophthalmic symptoms)

Suspicious Historical Elements

Facial trauma

Surgery

Allergic/inflammatory sinus disease

Imaging

CT scan

Sinus walls bow radially outwards

Thin or thick sinus walls

Bony erosions

Mucocele appears homogeneous and airless

45 year old male with left maxillary sinus mucocele

37 year old male with bilateral postoperative maxillary sinus mucoceles

Imaging MRI

Protein and water concentrations vary

Viscosity varies

Not best imaging modality

Good for differentiating mucocele from sinonasal tumors (particularly contrast enhanced)

Mucoceles have thin peripheral linear enhancement

Tumors have diffuse enhancement

Treatment

Surgical removal or drainage is the only way to prevent intracranial and/or orbital complications

Surgery External

Endoscopic

Both

External

Indicated if orbital or intracranial involvement

Good for fronto-ethmoidal mucoceles

Several different variations

Riedel

Killian

Lynch-Howarth

Lothrop

Riedels Procedure Removal of anterior wall and floor of frontal

sinus

Entire mucosal lining removed

Lynch-Howarth

Curved incision from inferomedial eyebrow, along upper third of nose

Medial wall of orbit perforated

Osteoplastic Flap

Cut is made through eyebrows

Scalp is lifted

Frontal sinus obliterated with fat

Bone replaced

Better cosmesis

Endoscopic Approach

Endoscopic management with marsupialization

Complete removal of the cyst lining is not required

Recurrence rates are near 0%

Goal is establishment of sinus drainage

Recurrence

Risk factors

Surgery during acute infection

Presence of multiple mucoceles

Significant extension outside the sinus wall

Surveillance

Periodic nasal endoscopy in the office is recommended to assess patency of ostium

Recurrences are few if adequate drainage is established

It can take many years for mucoceles to recur

Case Presentation 50 yo female

Referred for chronic sinus issues

Chief complaint of significant left facial pain and pressure for the past 9 years

PMH significant for allergic rhinitis and previous episodes of acute sinusitis

PSH significant for Le Fort I Osteotomy with maxillary advancement procedure done as a child

Dental cyst found on CT one year previously

Patient lost job and was without insurance so was not evaluated by OMFS

Case Presentation

Physical Exam

No polyps or masses

Extraocular muscles intact

Nasal mucosa showed no crusting, hypertrophy, or congestion

Case Presentation Dental cyst found on CT one year previously

Repeat CT

CT scan read expansile unilocular homogeneous lesion with thin sclerotic margins associated with the left posterior most tooth apex

Case Presentation

Patient was seen by OMFS

Curettage and lavage of the left maxillary sinus and I&D of abscess was performed

Pain and pressure resolved but returned two weeks later

Case Presentation

CT was reviewed in conjunction with an assessment of the surgery notes

Lesion was determined to be a mucocele abutting the floor of the maxillary sinus around her teeth

Case Presentation

Case Presentation

FESS and antral puncture with marsupialization of the maxillary mucocele

1 month after surgery patient had no more complaints of facial pain or pressure

Summary Mucoceles are late complications of sinus ostium

obstruction or mucous gland obstruction

Expansile lesions that are capable of bony destruction and compromise of surrounding structures

Endoscopic sinus surgery is the first choice for treatment

External approaches may be necessary

Sources 1. Flint, PW, Cummings CW. "Chronic Frontal Sinus Disease." Cummings

Otolaryngology: Head & Neck Surgery. Philadelpha, PA: Mosby Elsevier, 2010. Print.

2. Cagigal BP, Lezcano JB, Blanco RF, Cantera JMG, Cuellar LAS, Hernandez AV. Frontal Sinus Mucocele with Intracranial and Intraorbital Extension. Medicina Oral , Patologa Oral y Ciruga Bucal 2006; 11:E527-30.

3. Malard O, Gayet-Delacroix M, Jegoux F, Faure A, Bordure P, de Montreuil CB. Spontaneous Sphenoid sinus Mucocele Revealed by Meningitis and Brain Abscess in a 12-year-old Child. American Journal of Neuroradiology 2004; 25:873-875.

4. Yap SK, Yap EY. Frontal Sinus Mucoceles Causing Proptosis Two Case Reports. Annals Academy of Medicine Singapore 1998; 27:744-7.

5. Tseng CC, Ho CY, Kao SC. Ophthalmic Manifestations of Paranasal Sinus Mucoceles. Journal of Chinese Medical Association 2005; 68:260-4.

Sources 6. Rontal ML. State of the Art in Craniomaxillofacial Trauma: Frontal Sinus.

Current Opinion in Otolaryngology & Head and Neck Surgery 2008;16:381-6.

7. Moeller CW, Welch KC. Prevention and Management of Complications in Sphenoidotomy. Otolaryngologic Clinics of North America 2010; 43:839-54.

8. Natvig K, Larsen TE. Mucocele of the paranasal sinuses. The Journal of Laryngology & Otology 1978; 92:1075-82.

9. East D. Mucoceles of the Maxillary Antrum. The Journal of Laryngology & Otology 1985; 99:49-56.

10. Kariya S, Okano M, Hattori H, Sugata Y, et al. Expression of IL-12 and T helper cell 1 Cytokines in the Fluid of Paranasal Sinus Mucoceles. American Journal of Otolaryngology Head and Neck Medicine and Surgery 2007;28:83-6.

11. Har-El G. Endoscopic Management of 108 Sinus Mucoceles. Laryngoscope 2001; 111:2131-4.

paranasal-sinus-slides-2010-11-22.pdf

Documents

maxillary page

anatomy frontal sinus

anatomy maxillary sinus

osteoclasts page

sinusitis page

recirculated page

movement page

anatomy sphenoid sinus